SPECIALIST ACCREDITATION COMMITTEE MEDICAL TRAINING PROGRAMME OPHTHALMOLOGY APPROVED BY THE SAC ON 24 th January 2008 1
DEPARTMENT OF OPHTHALMOLOGY MATER DEl HOSPITAL MALTA MALTA ASSOCIATION OF OPHTHALMOLOGISTS SPECIALIST ACCREDITATION COMMITTEE 2
OPHTHALMOLOGY TRAINING PROGRAM Ophthalmology training programme Compiled by Mr Thomas Fenech FRCS FRCOphth Chairman Dept Of Ophthalmology Mater Dei Hospital Malta. Professor James Diamond MD FACS Director Vitreoretinal Service Tulane School of Medicine New Orleans USA Compiled December 2004 Revised December 2007 3
CONTENTS 1. Introduction 2. Administration 3. Goals and Objectives and Recommended Reading 4. Private practice policy 5. Patient Care 6. Surgical Privileges 7. Medical Records 8. Academic Requirements 9. Lecture Series 10. Evaluation Process 11. Grand Rounds 12. Journal Club 13. Meetings 4
INTRODUCTION At present there is no formal training programme in ophthalmology in Malta and all junior staff acquire experience in an apprenticeship style of training which is not structured in any way. At present all training is done at the ophthalmology department under the auspices of the department of health. It is our intention to organize a formal postgraduate training programme in ophthalmology in conjunction with the department of ophthalmology at Mater Dei hospital under the auspices of the specialist accreditation committee (SAC). The programme is to be a 5 year structured full time training programme and all trainees are to sit for the European board of ophthalmology exam at the end of their training programme if they have satisfied the faculty, a further 1 year training would be recommended for those trainees who have not satisfied faculty. Trainees would be encouraged to spend some time (at least 1 year) at the end of their 5 year programme at an overseas institution to gain a wider experience than is possible locally. The faculty is to include all consultant and senior registrar staff at St Luke s and Gozo general hospital. All efforts are to be made to have at least 6 high profile international visiting faculty who would come at a specific period every year to give didactic lectures, tutorials and clinical instruction to the trainees. The local requirements need to be evaluated to decide on the number of training posts however 2 to 3 posts every 2 years is possible. The postgraduate programme would require some funding to cover the costs of the visiting faculty, secretarial support and other ancillary services such as stationary etc. An estimate of the yearly budget to run this postgraduate training programme is between 12,000 to 14, 000 Malta Liri.( 28,000 to 32,000 Euros). If funds are available from the EU all efforts will be made to tap into these funds. The setting up of an ophthalmic postgraduate training programme is the only way forward in ensuring that the future of ophthalmology and quality care to our patients will continue; Without such a programme all trainees will proceed to an overseas institution as soon as possible with no obligation to return back home. Such a structured programme would encourage junior doctors to remain and train locally. 5
Requirements to enter the structured training programme include the following: 1. 12 months housejobs with 6 months in general medicine and 6 months in general surgery. 2. a further 12 months with at least 6 months experience in ophthalmology and I or work experience in neurology, neurosurgery, endocrinology/diabetes, ENT surgery or rheumatology. ADMINISTRATION The ultimate responsibility for all activities related to the programme is that of the Departmental Chairman. A committee to run the training programme is to be set up and this is to include the following: The training programme director (usually the departmental Chairman) Visiting Faculty representative Senior resident to represent all trainees (as an observer) Programme coordinator to be choosen from full time local faculty. SAC representative of Malta association of Ophthalmologists One representative from the Department of health to keep the department updated on the programme particularly regarding financial matters. The frequency of meetings is to be finalized at a later date Duties of the Senior Trainee 1. Supervision of all trainee activities, including teaching of all junior trainees and medical students. 2. Scheduling on-call rosters, consultations, grand rounds, presentations, etc. 3. Assuring staff supervision for surgery and clinics. 4. Securing final approval of the daily surgical schedules, being certain that all pre-op regulations, staff approvals and complete current work-ups have been met. 6
GOALS AND OBJECTIVES RECOMMENDED READING 7
I. General Objectives UNIVERSITY OF MALTA OPHTHALMOLOGY TRAINING PROGRAMME As in other specialty training, the objectives of the ophthalmology trainee programme are to enable the trainees to acquire general knowledge, values and attitudes that all physicians should have and to develop specific skills to treat eye diseases. This is primarily accomplished through actual patient care experience didactic teaching and tutorial instruction. The trainees undertake gradually increased responsibility for patient care under the supervision of faculty and develop skills and accumulate knowledge to manage eye problems. The department objectives can be summarized as follows: 1. Supervised direct patient care experience which allows the trainee to: a. Master ophthalmologic examination skills b. Formulate and workup differential diagnoses in eye diseases c. Mange clinical problems of increasing complexity d. Develop and exercise clinical and ethical decision making abilities. e. Develop patient communication techniques. f. Work efficiently as a member of the medical care team. 2. Graduated supervised and procedural and surgical experience including: a. Modem cataract and anterior segment techniques including strabismus and oculoplastics techniques. b. Anterior and posterior segment laser surgery. c. Exposure to all areas of subspecialty surgery. 3. To provide trainees with basic science and clinical knowledge through lecture, reading, and interactive conference, and review sessions. 4. To provide trainees with exposure to research and to motivate trainees to pursue projects. 5. Development of skills for teaching and medical writing. 6. Preparation for the European Board of Ophthalmology certification. II. Basic Science Knowledge Related to Ophthalmology Ophthalmology education should reflect a balanced mix in both the academic learning of medical sciences and in the clinical orientation of the training programme. 8
Today s rapid pace in scientific advances mandate the continuing familiarity with basic science information which is most pertinent to the specialty of ophthalmology and visual sciences. This section provides general outline of those basic science categories which are most useful and applicable in the clinical practice of ophthalmology. Trainees are encouraged to study about these subjects through their training. 1. Genetics 2. Embryology and molecular biology 3. Microbiology and immunology 4. Pharmacology 5. Pathology and neoplasia 6. Optics 1. Genetics Genetics has become a field of practical relevance during the last decade or two in many specialties, including ophthalmology. An understanding of the underlying mechanisms of inheritance and disease transmission is needed for the practice of clinical ophthalmology. It is necessary to have not only the basic knowledge of the technical aspects of genetic testing, and an understanding of the molecular interactions that are integral to gene function. The ophthalmic practitioners should have basic awareness of the biochemical basis of the genetics, DNA production and replication, cell division, and phenotypic manifestations of genetic expression in ocular disorders. The following areas are of particular significance to clinical practice: a. Chromosome identification including gene mapping b. Numerical and structural chromosomal abnormalities. c. Chromosomal abnormalities as identified by abnormal phenotypic expression. d. Hereditary and congenital ophthalmic disorders. e. Inheritance patterns for malignancies, particularly retinoblastoma. The application of basic genetic principles is becoming increasingly important in the understanding of pathophysiology of neoplasia in relation to cancer prevention, diagnosis and treatment. Particularly with the new discoveries related to retinoblastoma diagnosis and treatment, this area is significant in ophthalmology training. 2. Embryology and Molecular Biology Basic understanding of the development of the eye and the adnexal structures is important for the ophthalmologist, principally because of the many influences that may potentially alter this process. 3. Immunology and Microbiology Knowledge of basic science concepts regarding specific imthunologic and microbiologic associations in ophthalmology, particularly related to uveitis, external eye allergies, infections, and intraocular tumours as well as viral infections of the eye and the adnexa. Immunologic knowledge becomes more and more important to the practicing clinician 9
because of their frequent dealings with sexually transmissible diseases, surgical infections and uveitis. Immunologic aspects of aging are also of particular importance to the ophthalmologist since the great majority of ocular patients are elderly. Furthermore, the applications of cytotoxic and immunomodulatory drugs are expanding in all sub disciplines of ophthalmology. 4. Pharmacology The ophthalmologist as a clinician must have strong basic knowledge of pharmacologic principles. The medical and surgical care of the ophthalmology patient often demands a proper understanding of pharmacology, particularly in infectious diseases, glaucoma, and uveitis practice. Furthermore, the ophthalmology practitioner should be familiar with the ocular toxicity of systemic drugs, as well as potential side effects of the ocular medications. The ophthalmologist as a surgeon should be aware of the effects of preoperative, intraoperative and post operative of the medications including the agents used in local and general anaesthesia. The ophthalmologist should understand chemosurgery techniques such as Botulinum toxin injection for strabismus treatment. 5. Pathology and Neoplasia A thorough knowledge of microscopic pathologic anatomy is necessary for the understanding of ocular disorders and comprehensive care of the ophthalmology patient. In ocular disorders, the microscopic anatomy is readily comparable to the clinical findings of the slit lamp and ophthalmoscope. Therefore, histopathology is a very useful educational tool for the training of the ophthalmology specialist. An understanding of the molecular mechanisms and dysfunctions which are represented by oncogene expression and the ramifications for the development of noeplasia is necessary to appreciate the underlying pathophysiology of ocular and adnexal tumours. The basics of radiation toxicity and chemotoxicity should also be studied and an understanding of radiation physics should be acquired. The radiation toxicity to the globe as well as to the surrounding soft tissues result in a number of serious diseases, including cataract formation, radiation retinopathy, atrophy of growth in the orbital soft tissues, etc. The effects of U-V radiation on the human eye are also very for the ophthalmologist to study. 6. Optics The understanding of optical phenomena ~hysician, geometrical and quantum optics) is absolutely essential to be able to deal with clinical optical problems, refraction, retinoscopy, etc. 10
III. Professional Growth and Development 1. Communication The education of patients and effective communication with fellow health care professionals are integral elements of the ophthalmologist s responsibilities. Therefore, the trainee should develop these skills. Communication with the consultants and other specialists become very important in ophthalmology practice since this specialty is not within the main stream of medicine such as general surgery and paediatrics; the needs of the eye patients should be carefully explained to the colleagues and medical support personnel. 2. Ethics Physicians specializing in ophthalmology should be able to balance compassion with pragmatism in interacting with patients, families, other health care personnel, as well as others whose roles affect the patient s well being. Professional behaviour and medical ethics (applicable to all years of training) development can be summarized as follows: -Maintain confidentiality, passion and respect towards patients as individuals. -Respect life and vision. -Respect patient s privacy and modesty and use discretion in all private and public Conversations related to patients -Respect patient s social and religious beliefs. -Maintain honesty in all doctor/patient relations. -Develop skills in patient and family communications and doctorlpatient relationship. -Accept the responsibility and demonstrate reliability to gain the patient s trust and Dependability. -Understand the essential nature of collegiality and develop intrapersonal skills with other Health professionals. -Develop strong work ethics, be responsive to patients and co-workers and work as a member of the team. -Develop skills to explain medical conditions and treatment means to patient and family members in simplified but honest fashion. -Become organized and time efficient and develop skills to estimate the time to accomplish a task. 3. Information Today ophthalmologists are required to process increasingly greater amounts of information from different sources. They must become skilled in using al of the various computerized means at their disposal to facilitate this task. In light of the everexpanding body of medical knowledge, trainee must be able to collect and report statistical data and to evaluate medical literature in a critical and efficient manner in order to extract the content relevant to their practice. This includes the ability to use online databases to obtain medical information, analyze and interpret statistical data, systemically review literature by both traditional library methods and the use of computer search systems relative to ophthalmology and related areas. They should demonstrate the ability to use computer based word processing programs. 11
4. Continuing Medical Education CME, as the name implies, is an ongoing process to improve patient management. This continual process of learning should be an intricate part of the ophthalmologists professional lifetime. An ongoing commitment to CME should enhance the ophthalmologist professional performance and contribute to the effectiveness and the efficiency of his/her health care organization. Although the responsibility for the ophthalmologist s education is primarily lies with the individual itself, faculty members play a large role during residency to ensure that the trainees acquire proper habits related to this education process which they will be using for the rest of their lives. Since, at the end of the residency, the physician will assume the primary control over identifying his/her own learning needs, proper habits to set goals and objectives, to choose learning approaches, to select methods of evaluation should be given to the trainees during specialty training. With this attitude they can develop a life long pattern of effective, independent self assessment in the cognitive and technical aspects o the practice of ophthalmology. 5. Stress Management The practice of ophthalmology is a stressful profession, because of the fact that it deals with blindness. Significant stressful experiences can be encountered by the trainees during training, including concerns about difficult clinical problems which may lead to blindness, financial pressures, concerns about malpractice, etc. Trainees must learn to develop strategies to recognize and manage on unacceptably high stress levels and to seek help when necessary. The potential for substance and alcohol abuse among physicians and other health care professionals should be recognized by the trainees. IV. Objectives by Year I. First Year During the first 3-6 months of the first year, the trainees gain skills to interview and examine patients and correlate the information to formulate diagnostic hypotheses. Although this process is basically a continuation of their houseman training, their learning skills are geared toward ophthalmic problems, they gain knowledge of the eye disease through the study of the illness as well as the patient. Their sense of responsibility and respect toward ophthalmic pathologies and their commitment to deal with visual problems are moulded during this early period. They learn to orient their practice around visual loss, its possible causes, its manifestations and ultimately the impact of visual impairment on the individual patient and patient s family. First year trainees learn practical terminology regarding daily conduct of their specialty in the clinic and the operating room. In other words, they learn the language of the trade to which they are not exposed to a great degree in their school years or internship. The eye H&P is quite different from the systemic H&P and more equipment oriented. The conventional physical examination methods, such as, auscultation, palpation and observation with the naked eye are not very useful in ophthalmology. In the medical school students do not have enough exposure to essential ophthalmic 12
equipment, such as the biomicroscope, retinoscope, indirect ophthalmoscope, lensometer, etc. These specialized instruments, however, are absolutely necessary for basic eye examination and their applications should be mastered before anyone can effectively diagnose and treat eye patients. The same principle is also applicable to the instruments in the operating room which are quite different from general surgical tools. The majority of ophthalmic surgery is done under magnification with the utilization of specialized instruments, sutures, lasers, etc. The first year trainees primary objective is to familiarize himselfl herself with the overall organization of ophthalmology practice and equipment in the clinic and OR. They learn the names and proper uses for the instrcments and equipment, maintenance of these tools, the types of needles and sutures applied to ophthalmic surgery and the facts related to ophthalmic anaesthesia. Gradually the trainee is asked to assist in surgery by making simple incisions, dissections, and applications of haemostasis, irrigation, etc. Once he/she reaches to satisfactory level with the simple tasks of ophthalmic examination and feel comfortable with the related equipment, they are moved into more complex tasks, such as indirect ophthalmoscopy, retinoscopy, etc. The utilization of these examination techniques and the interpretation of findings take a long time for the beginner to feel comfortable with. That is why the trainees are encouraged not to miss any opportunity to examine the fundus with indirect ophthalmoscopy and retinoscopy and bring their questions to senior staff and consultants, particularly during the first year. During the 2 year, there is a constant monitoring of the trainees by the senior trainees and faculty... Furthermore, the trainees are exposed to all specialty consultants in clinics and surgery. After the second half of the first year, the trainees are introduced to simple, extraocular surgical procedures, including the chalazion curettage, removal of conjunctival and eyelid lesions, enucleation, evisceration, etc. Once the trainee proves to be competent with basic surgical techniques, he/she is allowed to do parts of cataract and glaucoma procedures under direct supervision with a consultant or Senior registrar. This is not routine for all trainees but for the ones who prove to be surgically competent and not done before the last quarter of the first year. During the last quarter of the year, the trainees are also allowed to do strabismus cases, particularly the horizontal muscle disorders. As a summary, by completion of PGY2 the trainees are expected to be knowledgeable and competent in the following areas: -Learn elementary refraction techniques and optical prescription principles. -Obtain a detailed ophthalmic history and review previous medical records and reports. -Perform a systemic H&P and develop complete differential diagnosis -Record a succinct H&P, including a risk assessment evaluation -Understand and utilize the notes of other medical personnel, including nurses, dieticians, laboratory technicians, etc. -Recognize abnormalities in basic radiologic and laboratory tests and learn normal 13
values and ranges. -Develop good habits to obtain consultations from related subspecialties, including infectious disease, EENT, etc. -Order and interpret basic laboratory tests, imaging procedures and evaluate the patient s cardiac, pulmonary and neurologic status. -Record a succinct ophthalmic H&P, including risk assessment evaluation, differential diagnosis and a treatment plan. -Dictate admit note, operative note and discharge summary -Perform a detailed ophthalmic examination, including full, refraction neuroophthalmological exam, biomicroscopy and indirect funduscopy. -Obtain a written informed consent for procedures (when necessary). -Develop a preoperative assessment of the patient by reviewing the medications the patient is currently taking, order medications as appropriate. -Learn the ocular implications of systemic medications, as well as the systemic complications of ophthalmic medications. ( 1 st and 2~ years). -Be able to write pre-anaesthetic and post-anaesthetic orders, and interpret the anaesthesia record. -Be familiar with intraoperative monitoring and know the dose range and complications of barbiturates, local anaesthetics, and paralyzing agents, and to know when and how to use epinephrine. -Be familiar with all periocular and retrobulbar local block techniques (1st and 2~ years). Be familiar with differential diagnosis of fever and evaluation and management of the febrile patients. -Know the surgical infection, diagnosis and management of surgical infection. -Know and apply the principles of incision and drainage. -Initiate topical, oral, intravenous and intraocular antibiotics and initiate treatment with appropriate choices. -Know the proper uses of prophylactic antibiotics. -Be able to monitor the antibiotic response and recognize drug related complications. -Know and apply the principles of prevention of nosocomial infections, sterile technique and universal precautions. -Recognize the different types of wound (clean vs contaminated) and be able to apply wound cleaning and debridement. -Understand the development of bacterial resistance. -Understand the epidemiology of communicable and sexually transmitted diseases. -Know the common opportunistic infections related to ophthalmology in ADS and other immunocompromised patients. -Develop facility and management of ophthalmic emergencies under supervision of senior trainees and staff. 14
Surgical Skills (PGY2): By the end of the first 6 months: -Know and apply proper operating room conduct and attire (scrub, gown and glove) properly. -Be familiar with basic ophthalmic equipment in the operating room, including the microscope, cauteries, lasers, drills, etc. -Be familiar with the common ophthalmic surgical instruments (blades, forceps, scissors, needle holders, etc.) suture materials, needles and their proper uses. -Perform minor surgical procedures, including the removal of sutures, chalazia, minor excisions of skin and conjunctival lesions. -Know the acute presentation f intoxication and management of the intoxicated patient. -Know the surgical implications of substance abuse. By the end of the second 6 months: -Perform as first assistant and expose the operative field. -Know how to obtain haemostasis and exposure under the microscope. -Be competent with management, including differential diagnosis between a wound infection, a haematoma and initiate therapy. -Perform debridement from conjunctival, corneal and skin wounds. -Know the different types and specifications of the lasers used in ophthalmology (first and second year). -Know the principles, medical applications and complications of lasers in ophthalmic procedures (first and second year). Anterior segment and External Disease The trainees familiarize themselves with the problems of the anterior segment, external eye and cornea. During this period they are given practical training on optics and hands-on experience on the use of the optic devices including automated refractometer, keratometer, and other related pieces of equipment; they also get practical training in contact lens fitting and low vision. During this rotation trainees scrub jointly with the staff in cataract cases, with intraocular lens (IOL) insertion, cornea and other anterior segment procedures. Glaucoma When the trainee rotates with the glaucoma specialist s/he received one-on-one teaching on different techniques related to glaucoma examination, including gonioscopy, examination of the optic nerve head, perimetry (Goldmann as well as automated). Glaucoma is a commonly seen disorder and the trainees in the program get ample opportunity to be exposed to surgical procedures including laser applications, filtering procedures, In all instances the trainee does participate in these surgeries with the faculty and in some instances s/he does parts of the cases under direct supervision. 15
Plastic Surgery/Orbit Trainees are instructed on diseases of eyelids and the orbit and they familiarize themselves with the imaging techniques including ultrasonography, CT, MRI, angiography and also with the specific needs of this subspecialty, including the use of exophthalmometer, LDS testing, etc. The trainees are exposed to many trauma cases and instructed in plastics and reconstructive procedures with emphasis on differences of cosmetic versus reconstructive surgery. Ocular Oncology & Pathology The trainees are given instruction on ocular and adnexal tumours and they attend to tumour patients in the clinic and surgery. The trainees also receive detailed instructions on external beam radiation therapy and brachytherapy and their applications in ophthalmic tumours and ocular complications of radiation. They also receive instruction on ocular and orbital ultrasonography. They also review histopathology slides under direct supervision of an ocular pathologist. Neuro-ophthalmology All neuro-ophthalmologic techniques, including perimetry, nystagmus examination and the entire spectrum of neurological and neuro-ophthalmological tests are learned during this rotation on a one-on-one basis with the neuro-ophthalmologist and also the consults are seen with the staff. Trainees review the visual field tests with the neuro-ophthalmologist. 2. Second Year During the second year the trainees are directly assigned to faculty members in different subspecialty areas. Not only do trainees get the opportunity to rotate through all subspecialty areas of ophthalmology available in Malta, but also have the opportunity of being exposed to different faculty members with different backgrounds and opinions. The idea is to establish a mentor relationship between trainees and faculty members and although these rotations are short the training during this period becomes most like a one-on-one tutorial program in which the faculty member carries the full responsibility of the trainees training: The second year rotations with subspecialty areas are as follows: Paediatric ophthalmology and strabismus Anterior segment and external disease Retina/vitreous 16
Paediatric ophthalmology and strabismus During this rotation the trainee is assigned to the paediatric ophthalmologist attending the clinics and rounds to learn eye examination in children and the examination of extraocular muscles. He/she scrubs with the paediatric ophthalmologist for strabismus cases, as well as other paediatric ophthalmology surgical procedures. During this rotation the trainee also gets exposure to orthoptic examination and funduscopic screening of premature infants for ROP at nursery rounds. The Trainee also spends time in the orthoptic department to familiarize with orthoptic skills Retina/Vitreous Trainees master the art of indirect ophthalmoscopy under the one-on-one training with the faculty. They also familiarize themselves with the techniques of ultrasonography and intravenous fluorescein angiography as well as optical coherence tomography. In this rotation the trainees review not only their own angiograms, but all cases as they are assigned by the retina specialists. During the same period the trainee familiarizes himseltlherself with the laser equipment and the applications of the laser surgery in the retina/vitreous diseases. The objectives of the second year trainees can be summarized as follows: -Increasing clinical decision making in management of general clinic and emergency patients. -Assisting in supervision and teaching of first year trainees -Training in and performance of adult and paediatric strabismus surgery and minor plastics procedures. -Learning techniques of anterior segment, glaucoma and cataract surgery and assisting staff in doing these surgeries themselves under supervision of staff. -Performance of simple surgical procedures such as pingueculum and pterygium excision, chalazion, tarsorrhaphy, etc. -Learning techniques of anterior and poster segment laser surgery. -Development of interpretive skills in assessing diagnostic tests such as fluorescein angiograms, radiologic images, etc. -Performance of ophthalmic consultations in a general medical hospital and emergency room. 3. Third Year Third year trainee s work with gradually increasing independency to improve their skills in clinical diagnosis and medical and surgical treatment of ophthalmic disorders. The objectives of the third year trainees can be summarized as follows: 17
-Training in the indication for, performance of, and complications of anterior segment and cataract surgery including basic techniques and advanced procedures. -Training in the indications for, performance, and complications of surgery in the subspecialty disciplines of glaucoma, retina, cornea, plastics, orbit and refractive surgery. -Assisting in the teaching and supervision of first and second year trainees. -Coverage of the ocular trauma service and learning of the medical and surgical management of ocular trauma. -Understanding of the indications for and uses of low vision aids. V. Detailed Learning Objectives by Subspecialty Cataract First year A. Cognitive Skills 1. Introductory refraction course covering the following: -basic ophthalmic optics -types of lenses -types of refractive error -retinoscopy techniques -subjective refraction techniques -use of instruments including: lensometer autorefractor phoropter keratometer Geneva lens clock 2. Lectures covering the following topics: -physical -intraocular lenses -anatomy of the globe -anatomy, physiology and embryology of the globe -introduction to low vision management and low vision aids 3. AAO Basic and Clinical Science Course -Section 11 Lens and Cataract -Section 2 Lens, Anatomy, Biochemistry, Metabolism and Embryology -Section 3 Optics and Refraction B. Acquired Skills 1. Slit lamp, retinoscopic and ophthalmoscopic evaluation and classification of lens opacities. 2. Subjective refraction techniques and retinoscopy 3. Observation of low vision professional 18
Second Year A. Cognitive Skills 1. Lens induced glaucoma and uveitis as covered in lecture and in AAO Basic and Clinical Science Course 2. Pre-operative evaluation of the cataract patient Systemic disease External and corneal disease Glaucoma and lens Glare Analysis A-scan ultrasonography; principles and practice History and techniques of cataract surgery hitracapsular Extracapsular Phacoemulsfication History and techniques of intraocular lens implantation 3. Acquisition of low vision refraction skills B. Acquired Skills 1. Preoperative evaluation of the cataract patient 2. Correlation of visual acuity with lens opacities 3. Surgical laboratory course and early graduated surgical experience Use of the operating microscope Basic techniques of wound closure with 10-0 nylon suture Techniques in ophthalmic anaesthesia 4. Principles and techniques of YAG capsulotomy 5. Refraction and prescribing of low vision aids to appropriate patients. Third Year A. Cognitive skills 1. Government and hospital regulation that apply to cataract surgery 2. Evaluation and management of complications of cataract and IOL implant surgery 3. Instrumentation and technique ofphacoemulsificatioin 4. Instrumentation and techniques of foldable lols. 5. Evaluation and management of endophthalmitis. B. Acquired Skills 1. A-scan ultrasonography and calculation of IOL power 2. Phacoemulsification lab, course and OR experience Anterior capsulotomy/capsulorrhexis Nuclear expression Instrumentation and techniques of irrigation and aspiration Intraocular lens implantation Phacoemulsification-sculpting, divide & conquer, phaco-chop 19
3. Postoperative management of the cataract patient Medications Astigmatism and suture removal Refraction Complications (early, late) 4. Management of the non-surgical low vision patient including assessment of patient needs, refraction of complex cases, referral to rehabilitation agencies. Cornea and External Disease First year A. Cognitive skills 1.Corneal anatomy and physiology 2.Ocular microbiology and antimicrobials 3.Ocular inflammation and immunology 4.AAO Basic and Clinical Science Course #3, #8 B. Acquired Skills 1. Slit lamp biomicroscopy 2. Management of corneal abrasions 3. Placement of pressure patches 4. Use of bandage contact lenses 5. Management of chemical burns 6. Management of infectious keratitis and performance of corneal scrapings for culture and sensitivity. 7. Removal of corneal and conjunctival foreign bodies. 8. Understanding of corneal pachymetry, specular microscopy and endothelial cell counts. 9. Use of keratometer and keratoscope 10. Interpretation of corneal mottling 11. Basic contact lens fitting and care Second Year A. Cognitive Skills 1. Medical and surgical management of partial and full thickness corneal perforations (cyanoacrylate glue, bandage contact lenses, conjunctival flaps. 2. Advanced contact lens fitting techniques 3. Surgical pterygium excision, use of conjunctival grafts 4. Temporary and permanent tarsorraphy 5. Anterior chamber tap 20
Third Year: A. Cognitive Skills 1. Essentials of corneal transplant surgery Penetrating keratoplasty Lamellar keratoplasty Patient selection Graft rejection and management Complications 2. Basics of refractive surgery (RK, PRK, LASIK) 3. Uses of conjunctival flaps Glaucoma B. Acquired Skills 1. Techniques in penetrating keratoplasty 2. Repair of corneal lacerations 3. Introductory keratorefractive surgery First Year A. Cognitive Skills 1. Knowledge of aqueous secretion and dynamics Angle anatomy Physiology of the ciliary body 2. Classification and mechanisms of different types of glaucoma 3. Glaucoma risk factors 4. Anatomy, physiology, and pathology of the optic nerve 5. Glaucoma pharmacology 6. AAO Basic and Clinical Science Course #10 7. Suggested texts: Shields, Textbook of Glaucoma Becker, Schaffer, Diagnosis and Therapy of Glaucoma B. Acquired Skills 1. Clinical evaluation of the glaucoma patient 2. Tonometry applanation ton op en Schiotz 3. Contact lens evaluation of the optic disc 4. Visual fields automated and manual interpretation of visual fields performance of visual fields 5. Development of gonioscopy skills Zeiss indentation Goldmann Second Year A. Cognitive Skills 1. Development of glaucoma management plans 2. Advanced interpretation and statistical analysis of visual fields 3. Differential diagnosis and workup o secondary and unusual glaucomas 21
4. Management of congenital and paediatric glaucoma 5. Suggested texts: Ritch, Shields, Krupin, The Glaucomas Anderson, Perimetry B. Acquired Skills 1. Accurate gonioscopy with indentation 2. Anterior segment laser surgery under supervision Argon and YAG iridotomy YAG capsulotomy Laser trabeculoplasty Laser iridoplasty and pupilloplasty 3. Cyclocryotherapy Third Year A. Cognitive Skills 1. Management of complex glaucomas 2. Understanding of indications, techniques, and complications of glaucoma surgery B. Acquired Skills 1. Glaucoma filtering surgery trabeculectomy and full thickness filtering surgery use of antimetabolites combined filtering and cataract surgery Seton surgery Surgical management of congenital glaucoma Vitreo-Retinal Disease First Year 2. Postoperative management needle revision of filtering blebs management of flat chamber laser suture lysis use of pharmacologic agents autologous blood TPA Viscoelastics A. Cognitive Skills 1. Retinal anatomy and physiology 2. Basic understanding of fluorescein/icg angiography and retinal Vascular disease 3. Understanding of mechanisms of retinal detachment 4. Understanding of macular anatomy and function and diagnosis of maeular diagnosis 5. Understanding of principles of photocoagnlation 6. AAO Basic and Clinical Science Course Section #12 22
B. Acquired Skills 1. Knowledge of major studies ETDRS DRS MPS GCCT Diabetic Vitrectomy Study 2. Understanding of peripheral retinal disease and vitreous pathology 3. Indications and complications of retinal photocoagnlation 4. Understanding of principles of retinal detachment repair 5. Diagnosis, treatment, complications of retinopathy of prematurity 6. Understanding of retinal vascular disease arterial and venous obstructions diabetic retinopathy hypertensive retinopathy anomalous vascular diseases peripheral vascular occlusive disease 7. Understanding of macular disease ARMD and choroidal neovascularizationi Dystrophies CME Central serous retinopathy 8. Understanding and application of electrophysiology 9. Recommended texts: Ryan, Retina Gass, Stereoscopic Atlas ofmacular Diseases Berkow, et al, Fluoresce in Angiography B. Acquired Skills 1. Indirect ophthalmoscopy with scleral depression 2. Use of the Mainster and wide angle exam lenses 3. Performance and interpretation of fluorescein and ICG angiography 4. Posterior segment laser surgery (indications, techniques, complications) diabetic focal and grid macular laser treatment pan retinal and sector photocoagulation treatment of choroidal neovascularization laser retinopexy 5. Electrophysiology-interpretaion of ERG, EOG, VER, dark adaptation 6. Use of ocular imaging techniques B-scan ultrasonography OCT Third Year A. Cognitive Skills 1. Knowledge of techniques for retinal detachment repair scleral buckling vitrectomy 2. Knowledge of surgical management of diabetic retinopathy macular hole repair epiretinal membrane peeling management of PVR use of heavy liquids 23
3. Recommended texts Ryan, Retina Michaels, Vitreous Surgery Hilton, et al, Retinal Detachment: Principles & Practice Yanuzzi, et al, The Retinal Atlas B. Acquired Skills 1. Fundus drawings of the retina with vitreoretinal relationships 2. Cryotherapy of retinal holes and other retinal pathology 3. Scleral buckling-indications, techniques, complications 4. Vitrectomy-indications, techniques, complications use of heavy liquids endophotocoagulation Ocular Oncology & Pathology Oncology First Year Second Year A. Cognitive Skills 1. Knowledge of categorization of intraocular tumours 2. Knowledge of differential diagnosis of leukocoria 3. Recognition of choroidal melanoma and differentiation from similar lesions 4. AAO Basic and Clinical Science Course Section #4 B. Acquired Skills 1. Slit lamp and ophthalmoscopic exam A. Cognitive Skills 1. Knowledge of management of options for different intraocular tumours familiarity with COMS 2. Knowledge of the histopathology of intraocular tumours B. Acquired Skills 1. Indirect ophthalmoscopic diagnosis and localization of intraocular lesions 2. Examination under anaesthesia for paediatric intraocular tumours 3. Interpretation of fluorescein angiography of intraocular tumours 4. Interpretations of A- and B-scan ultrasonography of intraocular mass lesions 5. Relevant surgical skills cyclodestruction of conjunctival, cornea and intraocular tumours laser photocoagulation 24
Pathology 6. Recognition of histopathologic appearance of intraocular and adnexal tumours 7. Recommended texts: Shields and Shields, Intraocular Tumours Spencer, Ophthalmic Pathology Third Year A. Cognitive Skills 1. Formulate differential diagnoses for tumours of the iris, ciliary body, choroids and optic disc 2. Understand prognostic significance of different types of ocular tumours and be able to guide workup for systemic involvement 3. Be able to discuss treatment alternative with patient. B. Acquired Skills 1. Surgical techniques and their complications plaque radiotherapy iridectomy and iridocyclectomy resection of conjunctival tumours enucleation First and Second Year A. Cognitive Skills 1. Basic ocular anatomy and histology 2. Understanding of the basic disease processes of the eye and their pathogenesis 3. Recognition of the histology of the major intraocular and adnexal disease processes B. Acquired Skills 1. Understand handling and processing of specimens in the laboratory 2. Knowledge of how to communicate with the pathologist regarding: special handling of specimens for special stains/em frozen sections 3. Participation in the cutting and gross examination of whole globes 4. Microscopic examination of active ophthalmology cases and teaching collections in all subdivisions of ophthalmic pathology. Neuro-Ophthalmology First Year A. Cognitive Skills 1. Further development of knowledge from first and second year B. Acquired Skills 1. Temporal artery biopsy 2. Optic nerve sheath fenestration: indications,technique,complications 25
Paediatric Ophthalmology and Strabismus First Year A. Cognitive Skills 1. Exraocular muscle anatomy 2. Physiology of ocular motility ductions versions and vergences Hering s and Sherington s laws Neuroanatomy of eye movement Vestibulomotor pathways 3. Ocular embryology developmental anomalies 4. AAO Basic and Clinical Course #6 B. Acquired Skills 1. Assessment of vision in the neonate, infant and child 2. Basic measurement of strabismus -Hirschberg -Krim sky -cover/uncover and alternate cover testing 3. Examination of the paediatric eye anterior segment red reflex and posterior segment exam Second Year A. Cognitive Skills 1. Binocular vision and amblyopia physiology of binocular vision diplopia, confusion and suppression normal and abnormal retinal correspondence classification and characteristics of amblyopia 2. Strabismus esodeviations exodeviations vertical deviations nystagmus special types of strabismus 3. Paediatric retinal disease inherited retinopathies retinopathy of prematurity 4. Paediatric glaucoma 5. Recommended texts: Van Noorden, Atlas of Sfrabismus Helveston, Strabismus Surgery Parks, Ocular Motility and Strabismus 26
B. Acquired Skills 1. Advanced ocular motility exam stereoacuity testing cycloplegic refraction retinoscopy test of binocularity and retinal correspondence special motor rests prism adaption testing 2. Extraocular muscle surgery indications techniques recession resection transposition Faden operation Adjustable techniques Complications 3. Treatment of retinopathy of prematurity indirect laser cryotherapy 4. Evaluation and treatment of paediatric nasolacrimal duct obstruction irrigation, probing and intubation of the nasolacrimal duct Third Year A. Cognitive Skills 1. Congenital cataracts workup and management 2. Complex ocular motility disorders 3. The opacified paediatric cornea and paediatric corneal surgery 4. Paediatric eyelid and orbital disease B. Acquired Skills 1. Paediatric cataract and anterior segment surgery indications, techniques and complications patients with uveitis special considerations paediatric IOL implantations 2. Paediatric glaucoma surgery goniotomy trabeculotomy filtering surgery 3. Surgical management of congenital eyelid deformities ptosis other lid malpositions Ophthalmic Plastic and Orbital Surgery First Year A. Cognitive Skills 1. Anatomy of the eyelids, orbits, and lacrimal system 2. Basic treatment of orbital and adnexal trauma 3. AAO Basic and Clinical Science Course Section #7 4. Recommended texts: Rootman, The Orbit Dutton, Anatomy of the Orbit and eyelids Rootman, Orbital Surgery 27
Second Year Third Year B. Acquired Skills 1. Evaluation of abnormalities of the orbit and eyelids Hertel exophthalmometry Measurement of ptosis 2. Lacrimal system evaluation and irrigation 3. Minor surgery excision of small eyelid lesions incision and curettage of chalazia abscess drainage electroepilation of eyelashes A. Cognitive Skills 1. Differential diagnosis of orbital disease 2. Aetiology, evaluation and treatment of eyelid malpositions 3. Diagnosis and management of eyelid lesions 4. Management of lacrimal system disease B. Acquired Skills 1. Radiologic evaluation of orbital fractures and lesions 2. Probing and intubation of the nasolacrimal duct 3. Repair of simple eyelid lacerations 4. Temporary tarsorrhaphy 5. Lateral canthotomy B. Acquired Skills 1. Excision of eyelid lesions and eyelid reconstruction 2. Enucleation and evisceration 3. Repair of eyelid 4. Cosmetic eyelid surgery 5. Repair of acquired and congenital eyelid malpositions 6. Lacrimal surgery 7. Orbital surgery fracture repair tumour biopsy/excision decompression 8. Recommended reading: AAO Basic and Clinic Science Course, Section #7 Stewart, Surgery of the Eyelid, Orbit and Lacrimal System Rootman, Orbital Surgery AAO Ophthalmology Monographs Volume 7 Fourth and Fifth year During the fourth and fifth year reinforcement of all goals and objectives with an emphasis on surgical hands on experience and completion of surgical and procedures logbook. 28
GOALS AND OBJECTIVES GLAUCOMA/ANTERIOR SEGMENT ROTATION Kan Janula, M.D. Franco Mercieca M.D. FRCOphth EUGME cognitive goals: medical knowledge, patient care and system based Eearning 1. Goal: to develop testable hypotheses concerning the diagnosis by obtaining a relevant history. Objectives: to he familiar with questions that will distinguish many different t~pes of glaucoma and diseases that mimic glaucoma -to elicit usethl descriptions and symptoms of loss of central and peripheral vision. -to identify patient with symptoms that may he related to issues of secondary gain -to inquire about specific external forces that could be the cause of the patient s disease process 2. Goal: to learn the basic ocular anatomy and its correlation with clinical examination and imaging procedures including nerve fiber layer analysis, stereo disc photographs and visual field aralysis. -. clinical evaluation 3. Goal: Clinical Evaluation: to gain proficiency in pcrlbnnance of anterior segm.ent and optic nerve exanunahon Objectives: -Slit lamp biomicroscopy of the anterior segment - Gonioscopy I. Indirect: be proficient with 4 mirror and 3-mirror e~aiuation of the anterior chamber angie, including the technique of compression gonioscopy. 2. Direct: be familiar with the K: oeppe lens gonioscopy system. 3. Be able to describe normal and pathological angie anatomy, -Optic Nerve - Normal anatomy and structure 2. Pathological anatomy, changes 3. Direct ophthaimosconic exam 4. Indirect ophthairnoscopic exam - Visual field know the mechanisms by which each method measures the visual Field and be able to recognize patterns of loss and distinguish them from false results. I. Goldmann 2. Automated perimetry (Humphrey and Octopus) 29
-Other tests 1. Nerve fiber layer analysis 2. Ultrasound biomicroscopy 3. Scanning laser ophthalmoscopy 4. Provocative testing: when to use it and interpretation of results 5. Ultrasonography: use B-scan to aid in diagnosis 4. Goal: To know the different types of glaucoma and understand the differences between them. Objectives: Open Angle Glaucoma -Primary open angle glaucoma 1. Associations, risks 2. Theories of pathogenesis 3. Diagnosis and treatment -Low tension glaucoma -Secondary open angle glaucoma; know causes, diagnosis and Rx 1. Pigmentary glaucoma 2. (Pseudo) Exfoliation glaucoma 3. Uveitic glaucoma 4. Steroid glaucoma 5. Lens induced glaucoma @hacomorphis, -lytic, -anaphylactic) 6. Traumatic (angle recession, hyphema, post-operative) 7. Systemic diseases (sarcoid, etc.) Angle Closure Glaucoma: know causes, diagnosis and R.x -Primary angle closure 1. Acute 2. Subacute 3. Chronic 4. Plateau iris -Secondary angle closure 1. Lens-induced 2. ICE syndrome 3. Neovascular glaucoma 4. Malignant glaucoma 5. Post-operative (epithelial and fibrous downgrowth, RD surgery) 6. Nanophthalmos (Particular risks and Rx) Pediatric Glaucoma -Congenital glaucoma 1. Genetics 2. Theories of pathogenesis 3. Diagnosis (signs, symptoms, differential) 4. Treatment 30
-Systemic diseases associated with pediatric glaucoma 1. Sturge-Weber syndrome 2. Neurofibromatosis 3. Marfan syndrome 4. Homocystinuria 5. Weill-Marchesani 6. Juvenile xanthogranuloma -Associations, congenital syndromes (Trisomy 21, Lowe, Stickler, etc.) -Associations, ocular abnormalities (aniridia, Axenfeld-Rieger, etc.) 5. Goal: To understand the medical management of different glaucomas Objectives: Phannacotherpaeutics: know the indications, contraindications and side effects of each a. Beta-blockers b. Adrenergic agonists c. Carbonic anhydrase inhibitors d. parasympathomimetics e. prostaglandins hyper osmotic agents g. new drugs (brimonidine, latanaprost) 6. Goal: to develop a comprehensive understanding of different surgical techniques used in the treatment of glaucoma Objectives: Surgical therapy: know the techniques, indications and complications * should be able to perform proficiently upon graduation from residency -laser 1. peripheral iridectomy* 2. laser trabeculoplasty* 3. gonioplasty/iridoplasty -filtering procedures L trabeculecotomy and goniotomy 2. trabeculectomy* a. post operative bleb management b. anti-metabolite use c. combined procedure * (with cataiact extraction) 3. fillthickness procedure 4. tube shunt -ciliary body ablation 1. cndocyclophotocoaguliation 2. trans-scleral eyclophotocoagulation* 3. cyclotherapy* -Postoperaitve care of all of the above procedures 31